Acute respiratory tract infections (ARTIs) are among the most common reasons for pediatric primary care visits and antibiotic receipt. Telemedicine outside of primary care settings has been associated with overuse of antibiotics for ARTIs in children. The quality of telemedicine when integrated within primary care for children is not clear. To compare antibiotic management during primary care visits conducted through telemedicine vs in-person. This retrospective, cross-sectional study analyzed visits for ARTIs in children younger than 18 years between January 1 and December 31, 2023, at 694 US primary care practices (including community health organizations, independent pediatric practices, and practice networks affiliated with large health systems). Analyses were performed between October 1, 2024, and February 12, 2026. Primary care telemedicine vs primary care in-person index visits. The primary outcomes were percentage of index visits with antibiotics prescribed and percentage with antibiotic management concordant with guidelines for visit diagnosis. Secondary outcomes included index visit diagnosis, follow-up visits within 14 days, and antibiotic prescription within 14 days. Weighted analyses were conducted using a propensity score model to estimate the probability of an ARTI index visit being conducted via telemedicine and estimated the average treatment effect associated with telemedicine. This study included 438 148 in-person and 11 482 telemedicine index ARTI visits at primary care practices by 302 817 children (mean [SD] age: 6.6 [4.7] years; 51.4% male). Antibiotic prescription occurred during 46.8% (95% CI, 45.1%-48.4%) of primary care in-person visits vs 34.6% (95% CI, 27.0%-42.3%) of primary care telemedicine visits in the propensity score-weighted model, with a difference of -12.1 (95% CI, -19.3 to -5.0) percentage points. Antibiotic management was guideline concordant for 86.2% (95% CI, 85.1%-87.3%) of primary care in-person visits vs 85.5% (95% CI, 80.5%-90.4%) of primary care telemedicine visits, with a difference of -0.7 (95% CI, -5.3 to 3.8) percentage points. The proportion of follow-up visits and antibiotic prescription within 14 days after initial visit did not vary significantly by index visit modality. In this cross-sectional study of primary care practices caring for children, telemedicine integrated within primary care was associated with judicious antibiotic prescribing without increased follow-up visits or subsequent antibiotics prescribed. Supporting primary care practices in offering telemedicine for acute concerns may be a strategy to limit unnecessary antibiotic receipt.
Primary care improves population health, yet access is a challenge in the US. It is unclear how primary care use, access, and access disparities have changed since widespread adoption of telemedicine during the pandemic. To quantify trends in primary care use and determine the role of telemedicine in primary care access and access disparities for traditional Medicare beneficiaries. Serial cross-sectional study using 2017-2023 100% claims and administrative data for traditional Medicare beneficiaries continuously enrolled and alive for the given year. Data were analyzed from October 2024 to July 2025. Primary care visits per beneficiary, primary care access (defined as ≥1 virtual or in-person primary care visit in the year), and primary care continuity (Bice-Boxerman Index). Among 258 324 127 person-years from 2017 to 2023, primary care visit rates decreased from 2.54 per person-year in 2017 to 2.27 per person-year in 2023, and access dropped from 61.9% to 59.8%. In 2023, virtual visits comprised 7% of primary care visits and 14% of beneficiaries who accessed primary care used telemedicine to do so. Disparities in access by race, geography, and income increased slightly from 2019 to 2023, and beneficiaries in historically underserved groups by race, geography, and income who accessed primary care were more likely than others to use telemedicine to do so. Primary care continuity decreased from 0.72 in 2019 to 0.65 in 2023; in 2023, continuity was slightly higher for those using telemedicine for primary care than for those who were not. This serial cross-sectional study found that across all traditional Medicare beneficiaries, primary care visit rates and access decreased, with virtual visits comprising a small share of previously in-person visits. Access disparities widened while those in underserved groups were more likely than others to use telemedicine for this access. Results suggest that telemedicine plays a small but potentially important role in primary care access.
Mentorship is foundational to the career development of academic physicians. During challenging times, mentees often look to their mentors for additional support and guidance; however, there are few empirical data on best practices for mentoring during times of crisis. To describe the best practices of award-winning research mentors during challenging times. Our exploratory qualitative study included in-depth interviews with mentors who were internal medicine faculty members and had received a clinical and translational research mentoring award between 2016 and 2024 at the University of Michigan Medical School. A semistructured interview guide was used, and interviews were conducted between July 14 and October 1, 2025, audio recorded, transcribed, and deidentified. Transcripts were analyzed through a descriptive content analysis approach and included both inductive and deductive coding. With the use of audio-recorded interviews, participant views were obtained on effective mentoring strategies in academic medicine focused on mentoring during the current climate of uncertainty related to research funding. In this qualitative study of 15 physician mentors (7 [46.7%] females; 8 [53.3%] males), key themes emerged from the qualitative data, organized into 3 domains: (1) tactical strategies mentors used during challenging times (eg, help mentees identify diverse funding sources, encourage consideration of alternative career options or areas of research focus), (2) psychological strategies used during challenging times (eg, provide emotional support, coach mentees' mindsets), and (3) overall mentoring philosophies and strategies for effective mentoring (eg, provide support and honest feedback, network on behalf of the mentee). This qualitative study of notable research mentors identified several strategies and philosophies that may be used to guide mentees during uncertain times. These approaches may transcend a specific crisis and be widely applicable during future challenging times in academic medicine.
This JAMA Internal Medicine Patient Page discusses different types of anxiety disorders, how they are diagnosed, and how they can be treated.
This Clinical Insights summarizes the pharmacological characteristics of dalbavancin and oritavancin and evaluates the clinical evidence supporting their use in infections beyond acute bacterial skin and skin structure infections for general internal medicine clinicians.
Pediatric hemovigilance is a nascent field in transfusion medicine. The lack of standardized hemovigilance reporting in the US makes it difficult to determine age-specific transfusion reaction rates and risks. To evaluate the rates and epidemiology of transfusion reactions reported to transfusion services in neonatal and pediatric populations. This cohort study analyzed transfusion reactions occurring in children younger than 18 years reported to 8 hospitals' transfusion services during April 1, 2019, through December 31, 2023. Data were evaluated from March 2024 to June 2025 using standardized data collection forms and associated electronic health records. Patients who received transfused blood products (red blood cells [RBCs], platelets, plasma, or cryoprecipitate) with at least 1 transfusion reaction reported to the transfusion service. Reaction rates per 100 000 products transfused were calculated. Pediatric transfusion reactions were characterized in detail, including reported severity and imputability; product type; patient age, sex, race, and ethnicity; and reported symptoms, premedication, and clinical management. The sample included 228 886 products transfused to 22 628 patients (median [IQR] age, 4.2 [0.3-12.4] years; 127 903 males [55.9%]). The products were transfused to patients of Asian (18 649 [8.2%]), Black (37 673 [16.5%]), White (93 824 [41.0%]), multiracial (3680 [1.6%]), other (68 857 [30.1%]), or unknown race (6203 [2.7%]) and Hispanic or Latinx (52 398 [22.9%]), non-Hispanic and non-Latinx (144 017 [62.9%]), and unknown ethnicity (32 471 [14.2%]). A total of 1165 imputable transfusion reactions were reported, with an overall reaction rate of 0.52% (95% CI, 0.49%-0.55%). Patients aged 5 to 11 years had the highest reported transfusion reaction rate (891.11 [95% CI, 799.81-989.11] per 100 000 products transfused). Platelet transfusions had the highest transfusion reaction rates (821.75 [95% CI, 754.14-893.80] per 100 000 products transfused), with allergic reactions being most common (506.04 [95% CI 453.30, 563.24] per 100 000 products transfused), whereas RBC transfusions had more reported febrile nonhemolytic transfusion reactions (FNHTRs; 296.20 [267.06, 327.67] per 100 000 products transfused) than other types of reactions. The most common symptoms were urticaria (69.6% [368 of 529 patients]) in allergic reactions, fever (96.5% [559 of 579 patients]) in FNHTRs, and acute respiratory distress (87.5% [21 of 24 patients]) in transfusion-associated circulatory overload (TACO); the most common treatments were antihistamines (80.3% [425 of 529 patients]) for allergic reactions, antipyretics (67.9% [393 of 579 patients]) for FNHTRs, and diuretics (83.3% [20 of 24 patients]) for TACO. Many patients (35.8% [107 of 299]) did not receive premedication after the first reaction in subsequent transfusions, regardless of reaction type. When transfusion reactions recurred, they were often of the same type (77.9% of reactions [120 of 154] after allergic reactions were allergic; 72.1% of reactions [98 of 136] after FNHTRs were FNHTRs). In this cohort study of pediatric transfusion reactions, reactions appeared to be age dependent, and rates of allergic reactions and FNHTRs were higher than rates from previously published, possibly underreported, predominantly adult data. These findings underscore the importance of pediatric-specific hemovigilance to improve recognition, reporting, and safety monitoring of transfusion reactions.
Appendiceal adenocarcinoma (AA) is a rare gastrointestinal cancer that frequently presents with peritoneal metastases; the standard of care for resectable peritoneal metastases from AA limited to the peritoneum is cytoreductive surgery (CRS) followed by hyperthermic intraperitoneal chemotherapy (HIPEC). Three serum tumor markers (TMs)-carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA19-9), and cancer antigen 125 (CA125)-may play a role in preoperative and postoperative risk estimation and decision-making in patients undergoing CRS-HIPEC. To evaluate the association of preoperative and postoperative serum TM levels with outcomes in patients with AA or goblet cell adenocarcinoma (GCA) undergoing CRS-HIPEC. This retrospective cohort study was conducted in a single quaternary referral cancer center. Software was used to query the MD Anderson internal patient database of patients with AA or GCA to identify a cohort receiving CRS with or without HIPEC between March 2016 and August 2024, with median postoperative follow-up of 35.6 months (range, 1.4-100.5 months). Data were analyzed from June 2024 to March 2025. Preoperative and postoperative levels of CEA, CA19-9, and CA125. Association of preoperative and postoperative serum TM levels with tumor burden and likelihood of complete CRS, disease-free survival (DFS), and overall survival (OS). A total of 421 CRSs were included in the study, 376 (89.3%) of which were performed in patients with AA (229 [60.9%] in females; median age at surgery, 56 [IQR, 47-64] years; 290 [77.1%] were complete CRS). In AA, greater vs lesser preoperative tumor burden was associated with increased median serum TM levels (CEA: 9.5 [IQR, 3.7-42.3] ng/mL vs 3.0 [IQR, 2.1-5.9] ng/mL; CA19-9: 31.1 [IQR, 10.0-102.3] U/mL vs 15.0 [IQR, 6.1-25.5] U/mL; CA125: 28.7 [IQR, 13.9-58.5] U/mL vs 11.5 [IQR, 8.0-17.3] U/mL; all P < .001), and after CRS vs before, percentages of patients with TM elevation were significantly lower (CEA: 77 of 223 [34.5%] vs 222 of 340 [65.3%]; CA19-9: 45 of 194 [23.2%] vs 117 of 324 [36.1%]; CA125: 13 of 203 [6.4%] vs 98 of 325 [30.2%]; all P < .001). However, complete vs incomplete CRS was associated with normalized TM levels in a greater percentage of patients (55 of 90 [61.1%] vs 7 of 52 [13.5%]; P < .001). Elevated vs normal preoperative TM levels were associated with increased rate of incomplete CRS (30 of 193 [15.5%] vs 1 of 95 [1.1%]; P < .001) and shorter DFS (hazard ratio [HR], 2.30; 95% CI, 1.46-3.64; P < .001) but not shorter OS (HR, 1.36; 95% CI, 0.71-2.60; P = .36). Postoperative TM elevation was associated with shorter DFS (HR, 3.73; 95% CI, 2.33-5.95; P < .001) and OS (HR, 4.10; 95% CI, 2.02-8.31; P < .001) in univariate analyses and also in multivariate analyses (HR, 3.34; 95% CI, 1.44-7.75; P = .005), whereas postoperative normalization of all TMs was associated with improved DFS (HR, 3.54; 95% CI, 2.01-6.23; P < .001) and OS (HR, 6.00; 95% CI, 2.06-17.46; P = .001) in univariate analyses and also in multivariate analyses (HR, 4.21; 95% CI, 1.33-13.35; P = .02). In this cohort study of CRS in patients with AA, elevated serum TM levels were associated with worse outcomes, suggesting that patients with postoperative TM elevation after complete CRS may represent a cohort with residual tumor that requires more cautious surveillance and that both preoperative and postoperative levels of CEA, CA19-9, and CA125 should be assessed in clinical practice.
This JAMA Patient Page describes the signs and symptoms of tetanus, the risk factors, vaccinations for prevention, and how it is diagnosed and treated.
Appropriate reporting of race and ethnicity in rheumatology research is critical to ensure equity and diversity of study participants and findings, as sociodemographic factors can affect outcomes, particularly for systemic lupus erythematosus (SLE). JAMA published guidance on reporting of race and ethnicity, highlighting the importance of reporting appropriately and building on emerging guidance. This study aimed to quantify reporting of race and ethnicity in high-impact rheumatology journals to assess adherence to accepted reporting recommendations. Studies investigating issues related to SLE published in three of the highest impact rheumatology journals between 1/1/2020-12/31/2023 were included. Manuscripts not involving human subjects were excluded. Two researchers (I.E. and H.B.) systematically abstracted sociodemographic variables to ensure consistent coding of data; conflicts were resolved by consensus. Descriptive statistics of each variable and reporting criteria were calculated. In all, 117 articles met inclusion criteria. Among these, 114 (97%) included any demographic data, 87 (74%) reported race, 51 (44%) reported ethnicity. Of those that reported race, 65 (75%) were comprised of a majority White race and only 7 studies (8%) met the Office of Management and Budget (OMB) minimum reporting criteria for race. Only 20 studies (23%) mentioned that racial and ethnic categories were self-reported by patients. Additionally, 32 studies included any comorbidities, and 18 studies included various other socio-economic factors. Despite known racial and ethnic disparities in SLE care and outcomes, reporting of race and ethnicity is not standardized across SLE research in rheumatology journals. Most publications do not meet minimum suggested race and ethnicity reporting criteria.
Syringe services programs (SSPs) are evidence-based interventions that reduce bloodborne infections and injection-related harms among people who inject drugs, yet access remains limited and geographically uneven across the US. To quantify the travel time, distance, and cost required to reach the nearest SSP from population-weighted census tracts nationwide and to examine differences by urbanicity, state, and SSP legality. This cross-sectional geospatial study linked all known SSP locations as of August 2024 to the population-weighted centroids of census tracts in the 50 US states and the District of Columbia. Analyses were conducted between December 2024 and February 2026. Population-weighted mean and median driving time, distance, and cost to access the nearest SSP, stratified by National Center for Health Statistics urban-rural county category and SSP legal status. Costs were estimated using 2024 Internal Revenue Service (IRS) medical mileage deduction rates and 2022 state-specific gasoline prices. In 1338 SSPs across 83 780 census tracts, the population-weighted mean 1-way driving time to the nearest SSP was 46.1 minutes (95% CI, 45.7-46.5 minutes) and the median was 23.3 minutes (IQR, 12.2-58.5 minutes). Altogether, 23.1% of the population lived more than 60 minutes from an SSP and 12.6% lived over 120 minutes away. The mean 1-way driving distance was 41.8 miles (95% CI, 41.3-42.2 miles). The mean 1-way driving cost was $8.77 (95% CI, $8.68-$8.86) using the 2024 IRS mileage rate and $6.91 (95% CI, $6.84-$6.98) using state mean gasoline prices in 2022. In states where SSPs were legal, mean driving time was 30.1 minutes (95% CI, 29.8-30.4 minutes) and mean cost by IRS mileage rates was $4.94 (IQR, $4.88-$5.00), compared with 110.7 minutes (95% CI, 109.6-111.8 minutes) and $24.19 (IQR, $23.92-$24.46) in states where SSPs were illegal. This cross-sectional study of travel burden to SSPs found substantial geographic and financial barriers to accessing SSPs across the US, particularly in nonmetropolitan areas. Targeting new SSPs to areas with the greatest travel burden could improve utilization and reduce drug-related morbidity.
Prepregnancy care and counseling optimize maternal health before conception to improve outcomes for mothers and infants. In the US, 66.4% of reproductive-aged women have at least 1 modifiable risk factor for adverse pregnancy outcomes. For all individuals desiring pregnancy, recommended interventions include folic acid supplementation; cessation of tobacco, alcohol, cannabis, and opioids; immunizations against hepatitis B virus, varicella, and rubella; and screening for syphilis and HIV. Folic acid use before pregnancy is associated with reduced fetal neural tube defects (relative risk [RR], 0.67; 95% CI, 0.52-0.87). Maternal tobacco smoking is associated with increased risks of stillbirth (summary RR [sRR], 1.46; 95% CI, 1.38-1.54), neonatal death (sRR, 1.22; 95% CI, 1.14-1.30), and perinatal death (sRR, 1.33; 95% CI, 1.25-1.41). Screening for and treatment of syphilis and HIV prior to and during pregnancy decrease rates of fetal and neonatal infection. Prepregnancy immunizations against hepatitis B virus, varicella, and rubella decrease neonatal infection and mortality. Individuals using tobacco, alcohol, cannabis, and opioids should receive counseling and treatment prior to pregnancy (eg, buprenorphine or methadone for opioid use disorder). For individuals with chronic disease, routine health examinations and contraceptive care in the year before conception can optimize pregnancy timing and are associated with decreased risk of severe maternal morbidity. Compared with planned pregnancies, unintended pregnancies are associated with increased risk of postpartum depression (15.7% vs 9.6%; adjusted odds ratio [aOR], 1.51; 95% CI, 1.40-1.70), preterm birth (9.4% vs 7.7%; aOR, 1.21; 95% CI, 1.12-1.31), and low infant birth weight (7.3% vs 5.2%; aOR, 1.09; 95% CI, 1.02-1.21). Weight loss prior to conception is recommended for individuals with a body mass index of 25 or greater because overweight and obesity are associated with increased risk of gestational diabetes, gestational hypertension, and cesarean delivery. Among patients with pregestational diabetes (type 1 or 2), hemoglobin A1c of less than 6.5% is associated with a decreased risk of fetal anomaly compared with hemoglobin A1c of 6.5% or greater. Cardiovascular complications such as hypertension and heart failure occur in 15% of pregnancies and are more common among those with preexisting cardiovascular disease. These patients should receive counseling on maternal and neonatal risk, monitoring, and medication management by specialists in cardiology and maternal fetal medicine. Prepregnancy counseling and care reduce maternal morbidity and neonatal morbidity and mortality. Primary care-based discussion of reproductive goals, immunizations, screening for infections and substance use, and risk-reducing interventions such as folate supplementation can optimize outcomes in individuals contemplating pregnancy.
This Viewpoint examines regulatory frameworks, limitations and exemptions, and policy implications of corporate practice of medicine doctrines.
This cross-sectional study examines the clinical setting in which medications that affect cognition in older adults are initiated and the persistence of taking such medications in the same class 1 year later.
Posttraumatic stress symptoms (PTSS) affect nearly 50% of children experiencing physical trauma. PTSS often persists after physical recovery and is associated with reduced health-related quality of life. To evaluate efficacy of the online therapist-assisted, trauma-focused Reducing Stress After Trauma (ReSeT) program in reducing PTSS in children after hospitalization for physical injury. A 2-arm randomized clinical trial with 1:1 assignment to the ReSeT program or usual care (UC) was conducted between 2021 and 2024 at 4 sites with level 1 trauma centers. Injured children ages 8 to 17 years were recruited from inpatient and short-stay units. Exclusion criteria included moderate to severe traumatic brain injury, preexisting severe psychiatric problems, current psychotherapy, developmental disorders preventing participation, interpersonal violence, hospitalization for more than 30 days, and injury-related death of friend or family. The ReSeT program has 8 online psychoeducational modules containing 3 to 4 short interactive videos that children completed independently. Modules are followed by an electronic health session with a therapist to practice cognitive behavioral skills and desensitization using trauma narrative techniques. Parents received optional psychoeducational resources. Generalized linear regression, controlling for baseline scores, was used to examine group differences on the Child Posttraumatic Stress Disorder Scale (CPSS) scores obtained 10 weeks (primary outcome) and 6 months (secondary outcome) after randomization. A total of 638 of 722 children screened positive at 1 week, and 271 children and caregivers completed the CPSS at 4 weeks. The highest value from each respondent on each item was summed, and 130 children (48%) had CPSS scores of 11 or greater, indicating potential eligibility for enrollment. A total of 93 children (72%; mean [SD] age, 11.7 [2.4] years; 56 male [60.2%]) were included in the study; 47 were randomized to the ReSeT cohort and 46 were randomized to the UC cohort. Intention-to-treat analyses indicated significant reduction in combined CPSS scores in the ReSeT vs UC cohorts, -4.2 points (95% CI, -7.6 to -0.8 points) at 10 weeks, which was maintained at the 6-month follow-up, -5.5 points (95% CI, -8.9 to -2.1 points). Findings of this randomized clinical trial show that the ReSeT program was an effective, brief, trauma-focused intervention for reducing PTSS after physical injury. It offers a potentially cost-effective, scalable program to address American College of Surgeons standards for psychological screening and treatment for children sustaining PTSS. ClinicalTrials.gov Identifier: NCT04838977.
暂无摘要（点击查看详情）
Anxiety disorders and symptoms are prevalent and burdensome, and patients are most likely to seek treatment in primary care settings. However, anxiety is underdetected and undertreated. This narrative review details behavioral and pharmacological treatment options that are feasible and effective in primary care. Screening for anxiety is recommended for primary care patients younger than 65 years. Given that anxiety often involves somatic symptoms, assessment should include patient-reported symptom measures, clinical interview, physical examination, and appropriate laboratory tests. For subthreshold symptoms (those that do not meet diagnostic criteria for anxiety disorders) and adjustment-related anxiety, starting with self-help and behavioral treatment is recommended. When deciding between behavioral, pharmacological, or combined treatment for anxiety disorders, consider the presentation, patient preferences, potential adverse effects, and treatment history, and engage in shared decision-making. Cognitive-behavioral therapy (CBT) is the first-line behavioral treatment for anxiety. Brief CBT in primary care delivered by embedded behavioral health clinicians is effective. First-line pharmacotherapy for anxiety disorders includes several selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors, which tend to be well tolerated without considerable long-term adverse effects. The main decision for pharmacological treatment is between a daily medication and a short-acting medication taken as needed for intermittent symptoms or while awaiting the effect of a daily medication. Benzodiazepines are not recommended due to risk of adverse effects, especially with long-term use. The Collaborative Care Management model, which involves collaboration between primary care clinicians, consulting psychiatrists, and care managers who monitor patient progress and provide behavioral treatment, improves anxiety outcomes compared to usual primary care. Clinicians should recognize common anxiety presentations and understand how to differentiate between anxiety and other psychiatric or medical conditions. Referring patients to behavioral health specialists for CBT and/or prescribing recommended pharmacotherapy with Collaborative Care Management can help to reduce patient morbidity and improve functioning.
This Guide to Statistics and Methods examines the population-level associations of guidelines for the use of doxycycline postexposure prophylaxis with sexually transmitted infection incidence.
This Viewpoint reviews evidence suggesting that controlled sodium chloride supplementation may facilitate decongestion in patients with decompensated heart failure.
This Viewpoint discusses how programs from the COVID-19 pandemic, including Acute Hospital Care at Home, have created the infrastructure to widely deliver hospital at home care, which could transform US health care delivery in the future.
暂无摘要（点击查看详情）